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Based on records review and interviews, the governing body failed to develop a 2012 institutional plan and budget for the facility and failed to approve a 2013 an institutional plan and budget per its plan of correction from the October 2012 complaint survey.

Refer to Tag A0073

Based on records review and interviews, the governing body failed to submit its institutional plan and budget to the appropriate health planning agency because there has been no approved institutional plan and budget for the facility since it was bought by the present owner in 2008.

Refer to Tag A0074

Based on records review and interviews, the governing body failed to review and update the institutional plan and budget annually, as there has been no approved institutional plan and budget for the facility since it was bought by the present owner in 2008.

Refer to Tag A0076

Based on records review and interviews, the facility failed to prepare its institutional plan and budget with the requisite input, as there has been no approved institutional plan and budget for the facility since it was bought by the present owner in 2008.

Refer to Tag A0077

Based on observations, records review and interviews, the Governing Body failed to provide oversight over the billing from and payments to contract and non-contract service providers. The facility failed to make timely payments to its electricity provider, resulting in power being disconnected to a portion of the facility.

Refer to Tag A0083

Based on records review and interviews, the governing body failed to develop a 2012 institutional plan and budget for the facility and failed to approve a 2013 an institutional plan and budget per its plan of correction from the October 2012 complaint survey.


Findings include:

Review of the facility document titled, "Rules and Regulations of the Governing Board," Article VIII, Section 8, revealed the following: "Facility Plans and Budgets. The Governing Board, together with the Hospital Administrator, shall develop short-term and long-term financial management plans including, but not limited to, annual capital and operating budgets, and a long-range master plan, to the end that the Hospital may effectively serve its community. Such plans shall be submitted to the Board of Directors or its designee for review and approval."

Review of facility records revealed no institutional plan and budget for 2012.

Review of Governing Body Meeting minutes from October 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 12/5/2012 in the Director of Nurses' (DON) office, the administrator reported the following:
-There was no current 2012 institutional plan and budget
-There is no Governing Body approved 2013 institutional plan and budget
-There has been no institutional plan and budget for the facility since it was bought by the present owner in 2008.

Based on record review and interview, the governing body failed to submit its institutional plan and budget to the appropriate health planning agency because there has been no approved institutional plan and budget for the facility since it was bought by the present owner in 2008.

Findings include:

Review of facility records revealed no institutional plan and budget for 2012.

Review of Governing Body Meeting minutes from October 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 12/5/2012 in the Director of Nurses ' (DON) office, the administrator reported the following:
-There was no current 2012 institutional plan and budget
-There is no Governing Body approved 2013 institutional plan and budget
-There has been no institutional plan and budget for the facility since it was bought by the present owner in 2008.

Based on records review and interviews, the governing body failed to review and update the institutional plan and budget annually, as there has been no approved institutional plan and budget for the facility since it was bought by the present owner in 2008.

Findings include:

Review of the facility document titled, "Rules and Regulations of the Governing Board," Article VIII, Section 8, revealed the following: "Facility Plans and Budgets. The Governing Board, together with the Hospital Administrator, shall develop short-term and long-term financial management plans including, but not limited to, annual capital and operating budgets, and a long-range master plan, to the end that the Hospital may effectively serve its community. Such plans shall be submitted to the Board of Directors or its designee for review and approval."

Review of facility records revealed no institutional plan and budget for 2012.

Review of Governing Body Meeting minutes from October 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 12/5/2012 in the Director of Nurses' (DON) office, the administrator reported the following:
-There was no current 2012 institutional plan and budget
-There is no Governing Body approved 2013 institutional plan and budget
-There has been no institutional plan and budget for the facility since it was bought by the present owner in 2008.

Based on records review and interviews, the facility failed to prepare its institutional plan and budget with the requisite input, as there has been no approved institutional plan and budget for the facility since it was bought by the present owner in 2008.

Findings include:

Review of facility records revealed no institutional plan and budget for 2012.

Review of Governing Body Meeting minutes from October 2012 to present revealed that no 2013 institutional plan and budget had been approved.

During an interview on 12/5/2012 in the Director of Nurses' (DON) office, the administrator reported the following:
-There was no current 2012 institutional plan and budget
-There is no Governing Body approved 2013 institutional plan and budget
-There has been no institutional plan and budget for the facility since it was bought by the present owner in 2008.

Based on observations, records review and interviews, the Governing Body failed to provide oversight over the billing from and payments to contract and non-contract service providers. The facility failed to make timely payments to its electricity provider, resulting in power being disconnected to a portion of the facility.

Findings include:

Review of Governing Body minutes from 11/08/2012 revealed the following: "Board Member #2 asked if all the vendors have been paid up to date. The administrator (staff #5) stated probably."

Review of a document titled, "Shelby Regional Medical Center Unpaid Bills Detail," dated 11/12/2012 revealed the following:
-A total of $190,442.71 owed to 79 service providers
-2 bills were outstanding since 2008
-1 bill was outstanding since 2009
-4 bills were outstanding since 2010
-39 bills were outstanding since 2011
-The remaining bills were from 2012

Review of a document titled, "Shelby Regional Medical Center Unpaid Bills Detail," dated 12/4/2012 revealed the following:
-A total of $117,960.06 owed to 76 service providers
-2 bills were outstanding since 2008 (same 2 from 11/12/2012)
-1 bill was outstanding since 2009 (same 1 from 11/12/2012)
-4 bills were outstanding since 2010 (same 4 from 11/12/2012)
-13 bills were outstanding since 2011
-The remaining bills were from 2012

During an interview on 12/5/2012 at 9:45am in the board member's office, board member #2 reported the following:
-The unpaid bills list, dated 11/12/2012 was presented as accurate and up to date
-He/she was unsure if all information coming from the administrator (staff#5) was accurate.

During an interview with on 12/5/2012 at 10:20am in the board member's office, board member #3 reported the following:
-The unpaid bills list, dated 11/12/2012 was presented as accurate and up to date
-He/she was unsure if all information coming from the administrator (staff #5) was accurate.

When the administrator (staff #5) presented the surveyor with the unpaid bills list dated 12/4/2012, the administrator reported that the list may not be correct and up to date.

During a facility tour on 12/4/2012 around 11:10am, the power to the central supply storage building went out. It was determined that the power had been disconnected by the electric company.

During an interview on 12/4/2012 at 12:15pm in the facility parking lot, an electric company employee #30 reported that the power had been disconnected to four of the buildings on the campus (not the main hospital building) due to non-payment. By 1:30pm the power was restored.

During an interview on 12/4/2012 in the Director of Nurses' office, the administrator reported that the late payment of the bill was due to clerical errors at the central billing office in another city. No explanation as to how the electric bill was into arrears enough to have power disconnected was given.

Based on observations, documents review and interviews, the facility failed to follow their policy and provide telemetry technician for the continuous monitoring of patients placed on telemetry.
On 12/04/2012 at approximately 10:30 AM, while touring the nurses' station with staff #6, there was no staff observed at the nurses' station. The telemetry monitor was observed unmanned by staff. The monitor was active with three cardiac rhythms. After approximately two minutes of time lapsed an RN returned to the nurses' station.
On 12/04/2012 a review was done of the facility's policy, Telemetry Admission Criteria, III. Responsibility: 3.2 The telemetry technician will be in attendance and closely observe for and record any abnormalities.
An interview on12/04/2012 at approximately 10:45 with staff #6 confirmed the telemetry monitor was left unattended. Staff #6 revealed, telemetry techs were not trained for the day shifts. The process would be for the ward clerk to notify the RN if an alarm were to go off. The RN would then return to the nurses' station and evaluate the telemetry monitor. Staff #6 confirmed the faciliy's telemetry policy was not being followed.

Based on observations and interviews, the facility had expired supplies available for patient use in the Emergency Room.
During the tour of the Emergency Room on 12/05/2012 at approximately 10:00 AM, the following items were observed with expired (beyond used) dates.
a. 2- Pediatric Quik-Combo RTS pads. Expired dates of 2012
b. 2- Endotracheal Tubes 3.0. Expired dates of 2011/08
An interview with staff #6 on 12/05/2012 at approximately 10:20 AM confirmed the expiration dates on the above items.
An interview with staff # 7 on 12/05/2012 at approximately 10:20 AM confirmed the expiration dates on the above items.

Based on observation and interview, the facility failed to assure patient supplies were stored in a safe and sanitary manner. There were 11 cardboard shipping boxes found in clean supply rooms. There was 1 box of cups found stored on the floor.

Findings include:

During a tour of the facility with staff #4 on 12/4/2012 at 10:30am, the following was observed:
-3 cardboard shipping boxes were found stored with clean supplies in the clean utility room
-5 cardboard shipping boxes were found stored with clean supplies in the clean supply room
-3 cardboard shipping boxes were found stored above open clean supplies in central supply
-1 box of cups was found stored directly on the floor in the clean supply room

During the tour, staff #4 confirmed these findings.